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Patient report
Meningoencephalitis in splenectomized patient caused by
concurrent Streptococcus pneumoniae and Herpes simplex
virus infection
Darko Nožić1, Radmila Rajić1, Nataša Živković1, Slobodan Ćirković2,
Dragutin Jovanović3, Branka Tomanović3, Branislav Antić4
Clinic of Infectious and Tropical Diseases,
Military Medical Academy, Belgrade, Serbia
2
Institut of Radiology, Military Medical
Academy, Belgrade, Serbia
3
Institut of Microbiology, Military Medical
Academy, Belgrade, Serbia
4
Clinic of Neurosurgery, Military Medical
Academy, Belgrade, Serbia
1
In this paper we have described a meningoencephalitis in
splenectomized patient caused contemporaneously by Streptococcus pneumoniae and Herpes simplex virus. The unusual
course of pneumococcal meningitis accompanied with worsening of the patient’s condition and repeated comatous status
directed clinical diagnosis to the new etiologic agent of meningoencephalitis. After antibiotic and antiviral therapy the
patient fully recovered.
Key words: Concurrent, Meningoencephalitis, Herpes, Pneumococcal.
Corresponding author:
Prof. dr. Darko Nožić,
Clinic of Infectious and Tropical Diseases,
Military Medical Academy,
Crnotravska 17, 11000 Belgrade, Serbia
Email: [email protected]
Received: 01. 06. 2007.
Accepted: 29. 06. 2007.
Introduction
Simultaneous infections of the central nervous system caused by different pathogens
are very rarely seen even in immunocompromised patients. In the adult population
up to 60 years of age, Streptococcus pneumoniae is responsible for about 60% of cases
of acute bacterial meningitis (1). Splenectomy is a predisposing factor for bacterial
infections especially caused by Streptococcus
pneumoniae (2, 3) Herpes simplex encephalitis is acute necrotising encephalitis with the
highest mortality rate and is the most common encephalitis occuring in immunocompetent patients (4, 5). In this paper we have
described meningoencephalitis in a splenectomized patient caused contemporaneously
by Streptococcus pneumoniae and Herpes
simplex virus. There is no similar report in
the current medical literature.
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Acta Medica Academica 2007; 36: 35-37
Case report
M.M. 41-year old man was referred to our
hospital after 24 hours of fever, sudden frontal headache, nausea, vomiting and progressive mental confusion. On admission, he
was unconscious, with high fever and nuchal rigidity. There were no neurologic signs
of lateralisation but skin abdominal reflex
function was absent. Lung and heart findings were normal, TA 100/70 mmHg, puls
96/min. He had a history of splenectomy
sixteen years ago, and he was not received
pneumococcal vaccine. First lumbar puncture performed on the day of admission
showed purulent cerebrospinal fluid (CSF)
with 151 cells/mm3, predomination of neutrophiles, undetectable level of glucose and
high protein level of 2,2 g/l. Blood and CSF
cultures have shown presence of Streptococcus pneumoniae. Cultivation of microorganisms was performed in Bacteriology
Department of Military Medical Academy.
Blood culture was performed on blood agar
and CSF culture on chocolate agar. Patient
treatment was started immediately with ceftriaxone 4g/day intravenously along with the
antiedematous therapy. On the second day
of the therapy, the patient become afebrile,
and he was in good condition,conscious,
but vesicles appeared on patient lips. On the
sixth day, the patient becamefebrile again,
he had difficulties with speech and his state
of consciousness was worsened resulting in
coma again. Repeated lumbar puncture has
showed blood in CSF with 1827 cells/mm3
(predominantly lymphocytes), decreased
glucose level of 1.9 mm/L (glucose in blood
5.7 mmol/L) and 1.6g/L of proteins. Cultivation CSF for presence of Herpes simplex
group viruses was performed in Virology
Department of Military Medical Academy
and were positive after six days in both CSF
samples.
Acyclovir (1,5 g daily) was introduced
into the therapy simultaneously with continuous administration ceftriaxon and anti36
Figure 1 Typical focal lesions in basal ganglia
edematous drugs. Two days after introduction of antiviral therapy the patient became
conscious, his neurologic findings revealedmotor aphasia, ptosis of the right eyelid,
hemiparesis of the right facial nerve and
pyramid deficit of the right side of the body.
Magnetic resonance imaging of brain has
showed typical focal lesions in basal ganglia
(Figure 1).
After two week successive medication and
the physical rehabilitation, the patient was able
to walk by himself and speak much better.
Discussion
Different types of immunodeficiencies are
predictive for infections even of central nervous system. Defects in humoral immunity
could lead to recurrent infections with encapsulated bacteria such as Haemophilus
influenzae or Streptococcus pneumoniae (6).
Immunodeficiency of T cells is found most
commonly accompanying HIV infection,
neoplastic disease, corticosteroids and cytotoxic agents use and is mainly associated
with infection with intracellular pathogens
(M. Tuberculosis, Herpes zoster virus, Herpes simplex virus, Cytomegalovirus Cryp-
Darko Nožić et al.: Concurrent meningoencephalitis
tococcus etc.) (6). There was no evidence of
congenital and acquired immunodeficiency
in our patient except splenectomy.
Splenectomized patients are likely to develop addiction to septic conditions caused
by incapsulated microorganisms, in the first
place by S. pneumoniae. According to some
reports splenectomized patients have twelve
times higher risk for developing severe sepsis comparing to patients with spleen (7). A
sepsis caused by S. pneumoniae in splenectomized patients occurs abruptly with possible
development of acute meningitis (8). Due to
the rapid development of meningitis, the
cerebrospinal fluid could be clear, without
cells or with a small number of cells, causing
diagnostic confusion.
The viral genome of Herpes simplex virus usually persists as a latent infection in
the trigeminal ganglion, and reactivation
could be caused by a number of stimuli including febrile illnesses, menstruation, sunlight, stress and immunosuppression (9).
There is experimental evidence of latent herpes simplex reactivation after pneumococcal
pnemonia in mice (10). The virus has a predilection for temporal lobes of the brain, but
extra temporal involvement could be found
in as many as 55% of patients (11). Focal
changes are identified especially in older patients (12). Concurrent infections of the central nervous system with microorganisms of
quite different taxa are extremely rare. Infections have been described with two bacterial
species(13), but CNS infections caused by
concurrent bacterial and viral microorganisms have not been reported so far. Unusual
course of pneumocoocal meningitis accompanied with worsening of the patient’s condition and repeated episodes of coma directed
clinical diagnosis to the new etiologic agent
of meningoencephalitis. In conclusion, the
unusual clinical course of bacterial meningitis sometimes could indicate a concurrent
viral infection.
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